Impact of Age, Frailty, and Dementia on Prescribing for Type 2 Diabetes at Hospital Discharge 2012-2016

BACKGROUND

The risks of intensive blood glucose lowering may outweigh the benefits in vulnerable older people.

OBJECTIVES

Our primary aim was to determine whether age, frailty, or dementia predict discharge treatment types for patients with type 2 diabetes (T2D) and related complications. Secondly, we aimed to determine the association between prior hypoglycemia and discharge treatment types.

DESIGN, SETTING AND PARTICIPANTS

We conducted a cohort study involving 3,067 patients aged 65-99 years with T2D and related complications, discharged from Melbourne's Eastern Health Hospital Network between 2012 and 2016.

MEASUREMENTS

Multinomial logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CI) for the association between age, frailty, dementia and hypoglycemia, and being prescribed insulin-only, non-insulin glucose-lowering drugs (GLDs) or combined insulin and non-insulin GLDs compared to no GLD. International Classification of Diseases-10 codes were used to identify dementia status and prior hypoglycemia; frailty was quantified using the Hospital Frailty Risk Score.

RESULTS

Insulin-only, non-insulin GLDs, combined insulin and non-insulin GLDs, and no GLDs were prescribed to 19%, 39%, 20%, and 23% of patients, respectively. Patients >80 years were less likely than patients aged 65-80 to be prescribed any of the GLD therapies, (eg. non-insulin GLDs [OR 0.67; 95%CI 0.55-0.82]), compared to no GLD. Similarly, high vs. low frailty scores were associated with not being prescribed any of the three GLD therapies, (eg. non-insulin GLDs [OR 0.63; 95%CI 0.45-0.87]). However, dementia was not associated with discharge prescribing of GLD therapies. Patients with a hypoglycemia-related admission were more likely than those not hospitalized with hypoglycemia to receive insulin-only (OR 4.28; 95%CI 2.89-6.31).

CONCLUSIONS

Clinicians consider age and frailty when tailoring diabetes treatment regimens for patients discharged from hospital with T2D and related complications. There is scope to optimize prescribing for patients with dementia and for those admitted with hypoglycemia.

Microstructural Characterization of Resistance Artery Remodelling in Diabetes Mellitus

INTRODUCTION

Microvascular remodelling is a symptom of cardiovascular disease. Despite the mechanical environment being recognized as a major contributor to the remodelling process, it is currently only understood in a rudimentary way.

OBJECTIVE

A morphological and mechanical evaluation of the resistance vasculature in health and diabetes mellitus.

METHODS

The cells and extracellular matrix of human subcutaneous resistance arteries from abdominal fat biopsies were imaged using two-photon fluorescence and second harmonic generation at varying transmural pressure. The results informed a two-layer mechanical model.

RESULTS

Diabetic resistance arteries reduced in wall area as pressure was increased. This was attributed to the presence of thick, straight collagen fibre bundles that braced the outer wall. The abnormal mechanical environment caused the internal elastic lamina and endothelial and vascular smooth muscle cell arrangements to twist.

CONCLUSIONS

Our results suggest diabetic microvascular remodelling is likely to be stress-driven, comprising at least 2 stages: (1) Laying down of adventitial bracing fibres that limit outward distension, and (2) Deposition of additional collagen in the media, likely due to the significantly altered mechanical environment. This work represents a step towards elucidating the local stress environment of cells, which is crucial to build accurate models of mechanotransduction in disease.

The FRAIL-NH Scale: Systematic Review of the Use, Validity and Adaptations for Frailty Screening in Nursing Homes

OBJECTIVES

To investigate frailty prevalence, cross-sectional associations, predictive validity, concurrent validity, and cross-cultural adaptations of the FRAIL-NH scale.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Frail residents living in nursing homes.

METHODS

MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched from January 2015 to June 2021 for primary studies that used the FRAIL-NH scale, irrespective of study designs and publication language.

RESULTS

Overall, 40 studies conducted across 20 countries utilized the FRAIL-NH scale; majority in Australia (n=14), followed by China (n=6), United States (n=3), and Spain (n=3). The scale has been translated and back-translated into Brazilian Portuguese, Chinese, and Japanese. Various cut-offs have been used, with ≥2 and ≥6 being the most common cut-offs for frail and most frail, respectively. When defined using these cut-offs, frailty prevalence varied from 15.1-79.5% (frail) to 28.5-75.0% (most frail). FRAIL-NH predicted falls (n=2), hospitalization or length of stay (n=4), functional or cognitive decline (n=4), and mortality (n=9) over a median follow-up of 12 months. FRAIL-NH has been compared to 16 other scales, and was correlated with Fried's phenotype (FP), Frailty Index (FI), and FI-Lab. Four studies reported fair-to-moderate agreements between FRAIL-NH and FI, FP, and the Comprehensive Geriatric Assessment. Ten studies assessed the sensitivity and specificity of different FRAIL-NH cut-offs, with ≥8 having the highest sensitivity (94.1%) and specificity (82.8%) for classifying residents as frail based on FI, while two studies reported an optimal cut-off of ≥2 based on FI and FP, respectively.

CONCLUSION

In seven years, the FRAIL-NH scale has been applied in 20 countries and adapted into three languages. Despite being applied with a range of cut-offs, FRAIL-NH was associated with higher care needs and demonstrated good agreement with other well-established but more complex scales. FRAIL-NH was predictive of adverse outcomes across different settings, highlighting its value in guiding care for frail residents in nursing homes.

Pharmacological treatment initiation for type 2 diabetes in Australia: are the guidelines being followed?

AIM

To determine the patterns and predictors of pharmacological treatment initiation for type 2 diabetes and whether treatment initiation is consistent with Australian clinical practice guidelines that recommend metformin monotherapy.

METHODS

Individuals aged 40-99 years initiating a non-insulin type 2 diabetes medication between July 2013 and February 2018 were identified from a 10% random national sample of pharmacy dispensing data. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the predictors of initiating sulfonylurea monotherapy, non-guideline monotherapy and combination therapy compared with metformin monotherapy. Predictors included age, sex, initiation year and comorbidities determined using the Rx-Risk comorbidity index.

RESULTS

Of the 47 860 initiators, [47% women, mean age 60.7 (sd 12.1) years], 85.8%, 4.6%, 1.9% and 7.7% received metformin monotherapy, sulfonylurea monotherapy, non-guideline monotherapy and combination therapy, respectively. Increasing age was associated with increasing odds of initiating sulfonylurea monotherapy and non-guideline monotherapy. Combination therapy initiation was less likely in women (OR 0.74, 95% CI 0.69-0.79) and people with more comorbidities (e.g. OR 0.36, 95% CI 0.29-0.44 for seven or more comorbidities vs. no comorbidities) but more likely in congestive heart failure (OR 1.42, 95% CI 1.22-1.65), cerebrovascular disease (OR 1.50, 95% CI 1.32-1.69) and dyslipidaemia (OR 1.29, 95% CI 1.19-1.40).

CONCLUSION

Treatment initiation in Australia is largely consistent with clinical practice guidelines, with 86% of individuals initiating metformin monotherapy. Initiation on combination therapy was more common in men and in those with fewer comorbidities.

The effect of bacteriochlorophyll derivative WST-D and near infrared light on the molecular and fibrillar architecture of the corneal stroma

A cross-linking technique involving application of Bacteriochlorophyll Derivative WST-11 mixed with dextran (WST-D) to the epithelium-debrided cornea and illumination with Near Infrared (NIR), has been identified as a promising therapy for stiffening pathologically weakened corneas. To investigate its effect on corneal collagen architecture, x-ray scattering and electron microscopy data were collected from paired WST-D/NIR treated and untreated rabbit corneas. The treated eye received 2.5 mg/mL WST-D and was illuminated by a NIR diode laser (755 nm, 10 mW/cm²). An increase in corneal thickness (caused by corneal oedema) occurred at 1-day post-treatment but resolved in the majority of cases within 4 days. The epithelium was fully healed after 6–8 days. X-ray scattering revealed no difference in average collagen interfibrillar spacing, fibril diameter, D-periodicity or intermolecular spacing between treated and untreated specimens. Similarly, electron microscopy images of the anterior and posterior stroma in healed WST-D/NIR corneas and untreated controls revealed no obvious differences in collagen organisation or fibril diameter. As the size and organisation of stromal collagen is closely associated with the optical properties of the cornea, the absence of any large-scale changes following treatment confirms the potential of WST-D/NIR therapy as a means of safely stiffening the cornea.

Dynamics of switching, adherence, and persistence of dipeptidyl peptidase-4 inhibitors use: A nationwide cohort study

AIMS

To characterise the patterns of switching, adherence, and persistence among adults aged ≥18 years with diabetes prescribed dipeptidyl peptidase-4 inhibitors (DPP-4is) in Australia.

METHODS

The analysis included 15,915 adults newly prescribed DPP-4is (sitagliptin = 9576; vildagliptin = 1130; saxagliptin = 1126; linagliptin = 3560; and alogliptin = 523). Multivariable logistic regression model was used to compare the non-adherence (proportion of days covered [PDC] <0.80) rates whereas Cox proportional hazards regression models were used to compare switching and non-persistence (≥90-day gap) among different DPP4-is over 12-months.

RESULTS

Overall, 36.0% (5722/15,915) of DPP-4i users were non-adherent and 30.0% (4775/15,915) were non-persistent at 12-months. Compared to sitagliptin, vildagliptin, linagliptin, and alogliptin were not associated with higher non-adherence and non-persistence. However, saxagliptin was associated with a higher likelihood of being non-adherent (odds ratio 1.41, 95% confidence interval [CI] 1.23-1.60) or non-persistent (hazard ratio 1.27, 95% CI 1.15-1.42) compared to sitagliptin. Just 3.2% of people switched between different DPP-4is. Compared to sitagliptin, people initiated on vildagliptin, saxagliptin, alogliptin, and linagliptin were more likely to switch.

CONCLUSIONS

We found no significant differences in the adherence and persistence rates between alogliptin, vildagliptin or linagliptin and sitagliptin. However, saxagliptin was associated with higher non-adherence and non-persistence compared to sitagliptin. Switching was lowest amongst users of sitagliptin.

An investigation of the features facilitating effective collaboration between public health experts and data scientists at a hackathon

OBJECTIVES

The objective of this study is to explore facilitating factors for collaboration at hackathons, intensive events bringing together data scientists ('hackers') with experts in particular subject areas.

STUDY DESIGN

This is a qualitative study.

METHODS

Semistructured interviews were conducted with organisers before and after the event. The initial exploratory interviews influenced the content of questionnaires which were distributed to all participants asking about their motivations and experiences. Thematic analysis was used to explore key features of collaboration.

RESULTS

Facilitating factors were clustered under the themes of preparation (the right amount of pre-event information, methods to maximise attendance and identification of suitable challenges), participants (enough people to progress and a mixture of skills and experience), working together (mutual understanding of the aim, getting the best out of each other, overcoming challenges together, effective facilitation and an enjoyable and valuable experience) and follow-up (recognised process for feedback and support for the development of prototypes).

CONCLUSIONS

The findings of the study provide insight into fostering collaboration in this context and provide evidence that may be used to tailor future events for the effective delivery of technological and marketing-based solutions to public health challenges. Hackathons provide a methodological advance with potential for broad public health application.

Novel hemodynamic structures in the human glomerulus

To investigate human glomerular structure under conditions of physiological perfusion, we have analyzed fresh and perfusion-fixed normal human glomeruli at physiological hydrostatic and oncotic pressures using serial resin section reconstruction, confocal, multiphoton, and electron microscope imaging. Afferent and efferent arterioles (21.5 ± 1.2 µm and 15.9 ± 1.2 µm diameter), recognized from vascular origins, lead into previously undescribed wider regions (43.2 ± 2.8 µm and 38.4 ± 4.9 µm diameter) we have termed vascular chambers (VCs) embedded in the mesangium of the vascular pole. Afferent VC (AVC) volume was 1.6-fold greater than efferent VC (EVC) volume. From the AVC, long nonbranching high-capacity conduit vessels ( n = 7) (Con; 15.9 ± 0.7 µm diameter) led to the glomerular edge, where branching was more frequent. Conduit vessels have fewer podocytes than filtration capillaries. VCs were confirmed in fixed and unfixed specimens with a layer of banded collagen identified in AVC walls by multiphoton and electron microscopy. Thirteen highly branched efferent first-order vessels (E1; 9.9 ± 0.4 µm diameter) converge on the EVC, draining into the efferent arteriole (15.9 ± 1.2 µm diameter). Banded collagen was scarce around EVCs. This previously undescribed branching topology does not conform to the branching of minimum energy expenditure (Murray's law), suggesting that even distribution of pressure/flow to the filtration capillaries is more important than maintaining the minimum work required for blood flow. We propose that AVCs act as plenum manifolds possibly aided by vortical flow in distributing and balancing blood flow/pressure to conduit vessels supplying glomerular lobules. These major adaptations to glomerular capillary structure could regulate hemodynamic pressure and flow in human glomerular capillaries.

SAXS4COLL: an integrated software tool for analysing fibrous collagen-based tissues

SAXS4COLL is an interactive computer program for reduction and analysis of small-angle X-ray scattering data from fibrous collagen tissues, combining data reduction, bespoke background subtraction, semi-automated peak detection and calibration.

This article provides an overview of a new integrated software tool for reduction and analysis of small-angle X-ray scattering (SAXS) data from fibrous collagen tissues, with some wider applicability to other cylindrically symmetric scattering systems. SAXS4COLL combines interactive features for data pre-processing, bespoke background subtraction, semi-automated peak detection and calibration. Both equatorial and meridional SAXS peak parameters can be measured, and the former can be deconstructed into cylinder and lattice contributions. Finally, the software combines functionality for determination of collagen spatial order parameters with a rudimentary orientation plot capability.

Microstructure and mechanics of human resistance arteries

Vascular diseases such as diabetes and hypertension cause changes to the vasculature that can lead to vessel stiffening and the loss of vasoactivity. The microstructural bases of these changes are not presently fully understood. We present a new methodology for stain-free visualization, at a microscopic scale, of the morphology of the main passive components of the walls of unfixed resistance arteries and their response to changes in transmural pressure. Human resistance arteries were dissected from subcutaneous fat biopsies, mounted on a perfusion myograph, and imaged at varying transmural pressures using a multimodal nonlinear microscope. High-resolution three-dimensional images of elastic fibers, collagen, and cell nuclei were constructed. The honeycomb structure of the elastic fibers comprising the internal elastic layer became visible at a transmural pressure of 30 mmHg. The adventitia, comprising wavy collagen fibers punctuated by straight elastic fibers, thinned under pressure as the collagen network straightened and pulled taut. Quantitative measurements of fiber orientation were made as a function of pressure. A multilayer analytical model was used to calculate the stiffness and stress in each layer. The adventitia was calculated to be up to 10 times as stiff as the media and experienced up to 8 times the stress, depending on lumen diameter. This work reveals that pressure-induced reorganization of fibrous proteins gives rise to very high local strain fields and highlights the unique mechanical roles of both fibrous networks. It thereby provides a basis for understanding the micromechanical significance of structural changes that occur with age and disease.

Three-dimensional arrangement of elastic fibers in the human corneal stroma

The cornea is the main refracting lens in the eye. As part of the outer tunic it has to be resilient, a property conferred by the organisation of the constituent collagen. It also has to be sufficiently elastic to regain its exact shape when deformed, in order not to distort the retinal image. The basis of this elasticity is not fully understood. The purpose of this study was to characterise in three dimensions the arrangement and distribution of elastic fibers in the human corneal stroma, using serial block face scanning electron microscopy. We have demonstrated that there exists a complex network of elastic fibers that appear to originate in the sclera or limbus. These appear as elastic sheets in the limbus and peripheral cornea immediately above the trabecular meshwork which itself appears to extend above Descemet's membrane in the peripheral stroma. From these sheets, elastic fibers extend into the cornea; moving centrally they bifurcate and trifurcate into narrower fibers and are concentrated in the posterior stroma immediately above Descemet's membrane. We contend that elastic sheets will play an important role in the biomechanical deformation and recovery of the peripheral cornea. The network may also have practical implications for understanding the structural basis behind a number of corneal surgeries.

•

We have characterised a complex system of elastic fibers in the posterior cornea.

•

These exist as sheets in the limbus that fenestrate and become fibers in the cornea.

•

We believe these fibers provide the elastic restoring force in the peripheral tissue.

•

This system should help explain some surgical properties of the cornea.

The micromechanics of the superficial zone of articular cartilage

OBJECTIVE

To investigate the relationships between the unique mechanical and structural properties of the superficial zone of articular cartilage on the microscopic scale.

DESIGN

Fresh unstained equine metacarpophalangeal cartilage samples were mounted on tensile and compressive loading rigs on the stage of a multiphoton microscope. Sequential image stacks were acquired under incremental loads together with simultaneous measurements of the applied stress and strain. Second harmonic generation was used to visualise the collagen fibre network, while two photon fluorescence was used to visualise elastin fibres and cells. The changes visualised by each modality were tracked between successive loads.

RESULTS

The deformation of the cartilage matrix was heterogeneous on the microscopic length scale. This was evident from local strain maps, which showed shearing between different regions of collagen under tensile strain, corrugations in the articular surface at higher tensile strains and a non-uniform distribution of compressive strain in the axial direction. Chondrocytes elongated and rotated under tensile strain and were compressed in the axial direction under compressive load. The magnitude of deformation varied between cells, indicating differences in either load transmission through the matrix or the mechanical properties of individual cells. Under tensile loading the reorganisation of the elastin network differed from a homogeneous elastic response, indicating that it forms a functional structure.

CONCLUSIONS

This study highlights the complexity of superficial zone mechanics and demonstrates that the response of the collagen matrix, elastin fibres and chondrocytes are all heterogeneous on the microscopic scale.

Micromechanical response of articular cartilage to tensile load measured using nonlinear microscopy

Articular cartilage (AC) is a highly anisotropic biomaterial, and its complex mechanical properties have been a topic of intense investigation for over 60 years. Recent advances in the field of nonlinear optics allow the individual constituents of AC to be imaged in living tissue without the need for exogenous contrast agents. Combining mechanical testing with nonlinear microscopy provides a wealth of information about microscopic responses to load. This work investigates the inhomogeneous distribution of strain in loaded AC by tracking the movement and morphological changes of individual chondrocytes using point pattern matching and Bayesian modeling. This information can be used to inform models of mechanotransduction and pathogenesis, and is readily extendable to various other connective tissues.

The structure and micromechanics of elastic tissue

Elastin is a major component of tissues such as lung and blood vessels, and endows them with the long-range elasticity necessary for their physiological functions. Recent research has revealed the complexity of these elastin structures and drawn attention to the existence of extensive networks of fine elastin fibres in tissues such as articular cartilage and the intervertebral disc. Nonlinear microscopy, allowing the visualization of these structures in living tissues, is informing analysis of their mechanical properties. Elastic fibres are complex in composition and structure containing, in addition to elastin, an array of microfibrillar proteins, principally fibrillin. Raman microspectrometry and X-ray scattering have provided new insights into the mechanisms of elasticity of the individual component proteins at the molecular and fibrillar levels, but more remains to be done in understanding their mechanical interactions in composite matrices. Elastic tissue is one of the most stable components of the extracellular matrix, but impaired mechanical function is associated with ageing and diseases such as atherosclerosis and diabetes. Efforts to understand these associations through studying the effects of processes such as calcium and lipid binding and glycation on the mechanical properties of elastin preparations in vitro have produced a confusing picture, and further efforts are required to determine the molecular basis of such effects.

A retrospective study of psychotropic drug use among individuals with mental illness issued a community treatment order

BACKGROUND

Community treatment orders (CTOs) are legal orders which require individuals with mental illness to accept treatment in the community. Previous studies report that long-acting injectable (LAI) antipsychotics are associated with CTOs, however, little is known about the specific treatment plans prescribed in CTOs. The objective of this study was to describe the patterns of psychotropic drugs prescribed to individuals issued a CTO, focusing on LAI antipsychotics, antipsychotic polypharmacy and high-dose antipsychotics.

METHODS

This was a retrospective cross-sectional study of 378 individuals randomly selected from a sample of 1317 individuals with a CTO expiry date up to and including 30 April 2010, taken from all 2856 individuals issued a CTO by the New South Wales Mental Health Review Tribunal, Australia, in 2009. De-identified information relating to individuals' treatment plans, demographic and clinical details were systematically extracted.

RESULTS

A total of 377 (99.7%) individuals were prescribed at least one antipsychotic. Of these, 310 (82%) were prescribed a LAI antipsychotic, either alone (45%), or in combination with, an oral antipsychotic (37%). Risperidone was the most prevalent antipsychotic, prescribed to 164 (43%) individuals. Antipsychotic polypharmacy was prescribed to 121 (32%) individuals and between 20% and 27% of individuals were prescribed high-dose antipsychotics. Antipsychotic polypharmacy accounted for 74-80% of individuals prescribed high-dose antipsychotics.

CONCLUSIONS

The results from this study confirm that LAI antipsychotics are commonly prescribed in CTOs. Antipsychotic polypharmacy was also common, and accounted for the majority of individuals prescribed high-dose antipsychotics. Further research is needed to determine the potential outcomes and implications of the patterns observed.

Late-onset progressive retinal atrophy in the Gordon and Irish Setter breeds is associated with a frameshift mutation in C2orf71

Progressive retinal atrophy (PRA) in dogs is characterised by the degeneration of the photoreceptor cells of the retina, resulting in vision loss and eventually complete blindness. The condition affects more than 100 dog breeds and is known to be genetically heterogeneous between breeds. Around 14 mutations have now been identified that are associated with PRA in around 49 breeds, but for the majority of breeds the mutation(s) responsible have yet to be identified. Using genome-wide association with 16 Gordon Setter PRA cases and 22 controls, we identified a novel PRA locus, termed rod-cone degeneration 4 (rcd4), on CFA17 (Praw  = 2.22 × 10(-8) , Pgenome  = 2.00 × 10(-5) ), where a 3.2-Mb region was homozygous within cases. A frameshift mutation was identified in C2orf71, a gene located within this region. This variant was homozygous in 19 of 21 PRA cases and was at a frequency of approximately 0.37 in the Gordon Setter population. Approximately 10% of cases in our study (2 of 21) are not associated with this C2orf71 mutation, indicating that PRA in this breed is genetically heterogeneous and caused by at least two mutations. This variant is also present in a number of Irish Setter dogs with PRA and has an estimated allele frequency of 0.26 in the breed. The function of C2orf71 remains unknown, but it is important for retinal development and function and has previously been associated with autosomal recessive retinitis pigmentosa in humans.

A tumor-related lymphoid progenitor population supports hierarchical tumor organization in canine B-cell lymphoma

BACKGROUND

Tumors have heterogeneous properties, which could be explained by the existence of hierarchically and biologically distinct tumor cells such as tumor-initiating cells (TICs). This model is clinically important, as TICs are promising targets for cancer therapies. However, TICs in spontaneous B-cell lymphoma have not been conclusively identified.

HYPOTHESIS/OBJECTIVES

Tumor cells with a progenitor phenotype exist in B-cell lymphoma, reflecting a hierarchical organization.

ANIMALS

Twenty-eight client-owned dogs with previously untreated B-cell lymphoma and 6 healthy dogs.

METHODS

This was a prospective study. Flow cytometry was used to identify lymphoid progenitor cells (LPCs) that coexpressed hematopoietic progenitor antigens CD34, CD117, and CD133, with lymphoid differentiation markers CD21 and/or CD22 in B-cell lymphoma. The polymerase chain reaction for antigen receptor rearrangements was used to analyze clonality and relatedness of tumor populations. A xenograft model with NOD/SCID/IL-2Rγ(-/-) mice was adapted to expand and serially transplant primary canine B-cell lymphoma.

RESULTS

LPCs were expanded in lymph nodes from 28 dogs with B-cell lymphoma compared with 6 healthy dogs (P= .0022). LPCs contained a clonal antigen receptor gene rearrangement identical to that of the bulk of tumor cells. Canine B-cell lymphoma xenografts in recipient mice that maintained LPCs in the tumors were recurrently observed.

CONCLUSIONS AND CLINICAL IMPORTANCE

These results suggest the presence of a hierarchy of tumor cells in B-cell lymphoma as has been demonstrated in other cancers. These findings have the potential to impact not only the understanding of lymphoma pathogenesis but also the development of lymphoma therapies by providing novel targets for therapy.

Hereditary cerebellar degeneration in Scottish terriers

BACKGROUND

Hereditary cerebellar degeneration is described in several dog breeds. This heterogeneous group of diseases causes cerebellar ataxia associated with cerebellar cortical degeneration.

OBJECTIVE

To report the clinical and histopathological features, and describe the mode of inheritance of hereditary cerebellar degeneration in Scottish Terriers.

ANIMALS

Sixty-two affected dogs recruited through the Scottish Terrier Club of America.

MATERIALS AND METHODS

Prospective, observational study: Owners of affected dogs were contacted for a description of clinical signs, age of onset, and disease progression. Medical records, videotapes of gait, and brain imaging were evaluated. When possible, necropsy was performed and the brain examined histopathologically. Prevalence of the disease was estimated and a pedigree analysis was performed to determine mode of inheritance.

RESULTS

Gait abnormalities were noted in the 1st year of life in 76% of dogs, and progressed slowly; only 1 of 27 dogs dead at time of writing was euthanized because of cerebellar degeneration. Clinical signs included wide based stance, dysmetria, intention tremor, and difficulty negotiating stairs and running. Cerebellar atrophy was detected on magnetic resonance imaging. On histopathological examination, there was segmental loss of Purkinje neurons, thinning of molecular and granular layers, and polyglucosan bodies in the molecular layer. Prevalence of disease was estimated at 1 in 1,335 American Kennel Club registered Scottish Terriers. Genetic analysis results are consistent with an autosomal recessive mode of inheritance.

CONCLUSION AND CLINICAL IMPORTANCE

A hereditary cerebellar degenerative disorder with a relatively mild phenotype has emerged in the Scottish Terrier. Genetic studies are needed.

Determinants of mental health stigma among pharmacy students in Australia, Belgium, Estonia, Finland, India and Latvia

BACKGROUND

Healthcare professionals commonly exhibit negative attitudes toward people with mental disorders. Few international studies have sought to investigate the determinants of stigma.

OBJECTIVE

To conduct an international comparison of pharmacy students' stigma towards people with schizophrenia, and to determine whether stigma is consistently associated with stereotypical attributes of people with schizophrenia.

METHOD

Students (n = 649) at eight universities in Australia, Belgium, India, Finland, Estonia and Latvia completed a seven-item Social Distance Scale (SDS) and six items related to stereotypical attributes of people with schizophrenia.

RESULTS

Mean SDS scores were 19.65 (+/- 3.97) in Australia, 19.61 (+/- 2.92) in Belgium, 18.75 (+/- 3.57) in India, 18.05 (+/- 3.12) in Finland, and 20.90 (+/- 4.04) in Estonia and Latvia. Unpredictability was most strongly associated with having a high social distance in Australia (beta = -1.285), the perception that people will never recover in India (beta = - 0.881), dangerousness in Finland (beta = -1.473) and the perception of being difficult to talk to in Estonia and Latvia (beta = -2.076). Unpredictability was associated with lower social distance in Belgium (beta = 0.839).

CONCLUSION

The extent to which students held stigmatizing attitudes was similar in each country, however, the determinants of stigma were different. Pharmacy education may need to be tailored to address the determinants of stigma in each country.

Pharmacotherapy of first episode psychosis in Estonia: comparison with national and international treatment guidelines

BACKGROUND AND OBJECTIVES

The pharmacotherapy of psychosis often differs between countries and with respect to treatment guidelines. Little is known about the treatment of first episode psychosis in countries of the former Soviet Union. The objective of the study was to analyse and describe the pharmacotherapy of first episode psychosis in Estonia.

METHODS

Case notes for consecutive patients with schizophrenia, schizotypal or delusional disorders admitted to the psychiatry clinics of the North Estonia Regional Hospital (NERH) and Tartu University Hospital (TUH) between September 2005 and September 2006 were retrospectively reviewed by a trained researcher. Treatment regimens were assessed according to prescribed doses, the incidence of antipsychotic polypharmacy and prescribing of conventional vs. atypical agents.

RESULTS

There were 234 patients admitted to the NERH and TUH, 142 of which were included in the final analyses (mean age 30.3 years for males, 40.4 years for females). Patients were most frequently treated with risperidone (n = 94), olanzapine (n = 43), chlorpromazine (n = 31), haloperidol (n = 21) and quetiapine (n = 24). Fourteen patients received concurrent treatment with two or more antipsychotics for three or more treatment days. Nine patients received antipsychotics in doses exceeding the maximum recommended doses in the British National Formulary.

CONCLUSIONS

The pharmacotherapy of first episode psychosis in Estonia was largely consistent with Estonian and international guidelines, however, the use of conventional antipsychotics and antipsychotic polypharmacy remained common. Estonian treatment guidelines may need to be revised to reflect the best available research evidence.

Inactivation of the p16 cyclin-dependent kinase inhibitor in high-grade canine non-Hodgkin's T-cell lymphoma

The significance of p16/Rb tumor suppressor pathway inactivation in T-cell non-Hodgkin's lymphoma (NHL) remains incompletely understood. We used naturally occurring canine NHL to test the hypothesis that p16 inactivation has specific pathologic correlates. Forty-eight samples (22 T-cell NHL and 26 B-cell NHL) were included. As applicable, metaphase- or array-based comparative genomic hybridization, Southern blotting, promoter methylation, and Rb phosphorylation were used to determine the presence, expression, and activity of p16. Fisher's exact test was used to test for significance. Deletion of p16 (or loss of dog chromosome 11) was restricted to high-grade T-cell NHL (lymphoblastic T-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified). These were characterized by a concomitant increase of tumor cells with Rb phosphorylation at canonical CDK4 sites. Rb phosphorylation also was seen in high-grade B-cell NHL (diffuse large B-cell lymphoma and Burkitt-type lymphoma), but in those cases, it appeared to be associated with c-Myc overexpression. The data show that p16 deletion or inactivation occurs almost exclusively in high-grade T-cell NHL; however, alternative pathways can generate functional phenotypes of Rb deficiency in low-grade T-cell NHL and in high-grade B-cell NHL. Both morphologic classification according to World Health Organization criteria and assessment of Rb phosphorylation are prognostically valuable parameters for canine NHL.

Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study

OBJECTIVE

To explore prospectively women's decision making regarding mode of delivery after a previous caesarean section.

MAIN OUTCOME MEASURES

The evolution of decision making, women's participation in decision making, and factors affecting decision making.

DESIGN AND METHODS

A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective.

SETTING

An antenatal unit in a large teaching hospital in Scotland and participants' homes.

SAMPLE

Twenty-six women who had previously had a caesarean section for a nonrecurrent cause.

RESULTS

Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section.

CONCLUSION

Women who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.

Genetic evaluation of Addison's disease in the Portuguese Water Dog

BACKGROUND

Addison's disease, also known as hypoadrenocorticism, has been reported in many individual dogs, although some breeds exhibit a greater incidence than the population as a whole. Addison's is presumed to be an autoimmune mediated hereditary defect but the mode of inheritance remains unclear. In particular, the heritability and mode of inheritance have not been defined for the Portuguese Water Dog although Addison's is known to be prevalent in the breed.

RESULTS

The analyses present clear evidence that establishes Addison's disease as an inherited disorder in the Portuguese Water Dog with an estimate of heritability of 0.49 (+/- 0.16); there were no differences in risk for disease across sexes (p > 0.49). Further, the complex segregation analysis provides suggestive evidence that Addison's disease in the Portuguese Water Dog is inherited under the control of a single, autosomal recessive locus.

CONCLUSION

The high heritability and mode of inheritance of Addison's disease in the Portuguese Water Dog should enable the detection of segregating markers in a genome-wide scan and the identification of a locus linked to Addison's. Though the confirmation of Addison's disease as an autosomal recessive disorder must wait until the gene is identified, breeders of these dogs may wish to keep the present findings in mind as they plan their breeding programs to select against producing affected dogs.

The Aberdeen Trauma Screening Index: an instrument to predict post-accident psychopathology

BACKGROUND

A key challenge in trauma care is the prevention of psychopathology. However, no definitive method of identifying individuals at risk of developing psychopathology exists. The Aberdeen Trauma Screening Index (ATSI) is a brief screening tool developed for use in a clinical setting by non-mental health professionals to facilitate the early identification of individuals most at risk of psychopathology 3-months post-accident.

METHODS

The ATSI derived from a prospective study of a 150 out of an initial pool of 213 consecutive admissions to the Orthopaedic Trauma Unit and the Accident and Emergency Department of Aberdeen Royal Infirmary. Potential predictors were identified by a comprehensive assessment conducted within 1-week post-accident. Outcome at 3-months post-accident was measured using 'caseness' according to the General Health Questionnaire (GHQ-28).

RESULTS

The ATSI is based on a final model comprising only seven variables with a sensitivity of 79% and specificity of 65%. A predictive index score (0-100) was produced to ensure the practical utility of the ATSI in a clinical setting. A ROC curve was constructed to illustrate the relationship between sensitivity and the specificity values with their corresponding threshold scores. On the basis of a prevalence rate of 55% 'caseness', as identified in the present study, a cut-off point of 45 provides the optimal outcome with a sensitivity value of 70% and a specificity value of 71%.

CONCLUSIONS

The ATSI can accurately identify those most at risk of developing psychopathology 3-months post-accident in a sample of accidentally injured adult subjects recruited as consecutive admissions to an urban hospital in the North East of Scotland. However, to establish the generalizability of these findings, it is important that the ATSI be validated in both similar and diverse populations.

Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? A retrospective analysis of routinely collected data

OBJECTIVE

To determine whether the higher levels of obstetric intervention and maternity service use among older women can be explained by obstetric complications.

DESIGN

A retrospective analysis of routinely collected data from the Aberdeen Maternity and Neonatal Databank.

PARTICIPANTS

All residents of Aberdeen city district delivering singleton infants at the Maternity Hospital 1988-1997 (28,484 deliveries).

MAIN OUTCOME MEASURES

Odds ratios for each intervention in older maternal age groups compared with women aged 20-29. Interventions considered include obstetric interventions (induction of labour, augmentation, epidural use, assisted delivery, caesarean section) and raised maternity service use (more than two prenatal scans, amniocentesis, antenatal admission to hospital, admission at delivery of more than five days, infant resuscitation, and admission to the neonatal unit).

METHODS

Logistic regression was used to investigate the association between maternal age and the incidence of interventions. The odds ratios for each intervention were then adjusted for relevant obstetric complications and maternal socio-demographic characteristics.

RESULTS

Levels of amniocentesis, caesarean section, assisted delivery, induction, and augmentation (in primiparae) are all higher among older women. Maternity service use also increases significantly with age: older women are more likely to have an antenatal admission, more than two scans, a hospital stay at delivery of more than five days, and have their baby admitted to a neonatal unit. Controlling for relevant obstetric complications reveals several examples of effect modification, but does not eliminate the age effect for most interventions in most groups of women.

CONCLUSIONS

Higher levels of intervention among older women are not explained by the obstetric complications we considered.

Endometriosis. Will identifying risk factors enable an early diagnosis?

BACKGROUND

Endometriosis is a common condition seen in general practice, affecting 10% of women of reproductive age. Recognition of risk factors on history and examination can lead to an earlier diagnosis and appropriate referral. This may ultimately lead to improved quality of care for women with symptoms of endometriosis.

OBJECTIVE

This article aims to identify risk factors in the clinical history and examination that may indicate a more likely diagnosis of endometriosis in women presenting to their general practitioner.

DISCUSSION

Some risk factors stand out in the literature as increasing the likelihood of a diagnosis of endometriosis. The GP can utilise these factors to help identify women at risk and those who would benefit from referral for diagnostic laparoscopy. The early diagnosis of endometriosis means that effective medical and surgical treatments can be used to control symptoms and improve the long term outcome for patients.

Temporal changes in soil properties at an upland Scottish site between 1956 and 1997

The aim of this study was to examine the frequency with which soil samples require to be taken in order to determine significant temporal changes in soil properties. The examination was carried out using data from Glensaugh Research Station in north-east Scotland where podzolic soils were sampled in 1956, 1977 and 1997, and by re-analysis of archived material. Significant differences in chemistry due to storage were detected, particularly decreases in pH of air-dried organic soils. In these cases original data were used for statistical analysis to establish changes between 1956 and 1997. Temporal changes were found for exchangeable Ca and Mg which generally decreased with time throughout the soil profile, whereas exchangeable H increased. Derived data, such as percent base saturation, declined dramatically due to decreases in exchangeable base cations. Similar podzolic soils were sampled at an adjacent Environmental Change Network (ECN) site in 1993. Application of statistical techniques to the ECN soil chemistry data allowed an estimation of the detectable change between any two years. These data along with the rates of temporal change from 1956 to 1997 allowed the calculation of the number of years required for measurable changes to be achieved. These changes and sampling intervals vary among different horizons and chemistries. Although they are site-specific, they do confirm that the current ECN protocols of a 5-year and 20-year sampling would be appropriate in order to detect changes in soil properties over time at this site.

Cerebellar degeneration in Old English Sheepdogs

OBJECTIVE

To evaluate related and unrelated Old English Sheepdogs (OESD) by clinical examination, histologic evaluation, and pedigree analysis to determine whether cerebellar degeneration develops in this breed and whether there are genetic implications.

DESIGN

Case study and pedigree analysis.

ANIMALS

24 clinically normal or affected OESD; brain tissue specimens from 25 unaffected or affected OESD.

PROCEDURE

Twenty-four OESD that were chosen because of a family history of gait abnormalities were given physical and neurologic examinations to determine whether they had clinical signs of cerebellar degeneration. Tissue specimens from 25 brains of OESD were examined histologically. Nine OESD that were determined to have cerebellar degeneration histologically as well as 2 clinically affected littermates of the histologically confirmed affected OESD were included in the pedigree analysis. Standard statistical evaluation of pedigrees for hereditary conclusions was used.

RESULTS

Twelve of the 24 OESD evaluated by neurologic examination had a progressive gait abnormality. Clinical signs of cerebellar degeneration typically started later in life in OESD, compared with description for other dog breeds, and progressed ore slowly. Results of pedigree analysis revealed that 11 of 49 dogs were affected in 9 litters, providing an affected-to-total ratio of 22.49%.

CONCLUSIONS AND CLINICAL RELEVANCE

Results of our study indicate that a slowly progressing late-onset form of cerebellar degeneration develops in OESD, and the mode of inheritance is by an autosomal recessive gene.

Supporting staff in employment: the emotional wellbeing of staff in an NHS psychiatric hospital

OBJECTIVE

The objective of this study was to assess the emotional wellbeing of a broad sample of NHS employees in a psychiatric setting; to seek their views on sources of distress; and to identify preferred ways of dealing with it.

DESIGN

A cross-sectional postal survey, employing two questionnaires: GHQ-28, and a semi-structured questionnaire. These were sent to a nominal 50% sample (n = 599).

SETTING

The population was the staff of a large Scottish psychiatric service.

RESULTS

A 47.9% response rate was achieved; 32.9% of respondents exceeded a cut-off score of four on the GHQ-28. Neither occupational, group nor gender effects were significant on this measure. The reporting of emotionally-distressing problems affecting their performance was found to be more common amongst doctors; males, overall, showed a non-significant trend towards having been affected more than females by such problems; and older staff (above 45) were affected significantly more often than younger staff. Almost a third of staff were unaware of the availability of an internal organisational resource (the Occupational Health service).

CONCLUSION

NHS Trusts should ensure the culture at work is appropriate from a preventative point of view and be aware that factors outwith the workplace can affect employees emotional wellbeing and performance. Preventative and supportive measures to minimise psychological distress in the workforce should be considered; the Scottish Needs Assessment Programme: Mental Health in the Workplace offers useful guidance.

Rupture of flexor pollicis longus tendon: a complication of volar plating of the distal radius

We report three complete ruptures and one partial rupture of the flexor pollicis longus tendon in association with the insertion of a volar plate for the treatment of fracture of the distal radius. Rupture was associated with the chronic use of steroids.

Hereditary polioencephalomyelopathy of the Australian cattle dog

A vacuolar degeneration affecting primarily the gray matter in the central nervous system (CNS) of young Australian Cattle Dogs is described. An initial presentation of seizures was followed by a progressive spastic tetraparesis. Grossly evident bilateral and symmetrical foci of malacia were in the nuclei of the cerebellum and brain stem and the gray matter of the spinal cord. Microscopically, vacuolation of glial cells, dilation of the myelin sheaths and reactive astrocytosis characterized mild CNS changes. More advanced lesions displayed progressive dissolution of the neuropil, prominent vacuolation of reactive astrocytes, numerous glial fibrillary acidic protein-positive coiled astrocytic processes, neuronal vacuolation and loss with relative sparing of large neurons. Ultrastructurally marked mitochondrial accumulation and swelling were seen in astrocytes. In the appendicular muscles, changes interpreted as long-term denervation atrophy accompanied by widespread expression of the neonatal isoform of myosin were observed. The character of the neurological sings, the nature and the distribution of the lesions within the neuroaxis have not been reported in domestic animals. An inherited biochemical defect, possibly mitochondrial, is proposed as the cause. Selected conditions with a bilateral and symmetrical distribution affecting the gray matter of domestic animals are summarized.

Autopsy of teleosts from contaminated areas

A systematic procedure provides one method of assessing xenobiotic-induced abnormalities in fish following environmental exposures. Behavioral, external (or gross), histopathological, and internal organ changes allow determination of the severity of toxicant impact on an endemic population provided a sufficient number of specimens is analyzed. Over the past 15 years, these methods have led to the establishment of causal factors in metal- and metalloid-induced toxicity.

Asphyxiating laryngeal cyst

Cysts of the larynx are uncommon lesions that on rare occasions may cause sudden death. We report herein the asphyxial death by an obstructing vocal cord cyst in a woman whose body was found in a setting that aroused suspicions of foul play. Features of this case and the autopsy findings are compared with a literature review of laryngeal cysts.

Psychometric prediction of psychogeriatric day care outcome

A comparison was made between sets of psychometric variables [the Clifton Assessment Procedures for the Elderly (CAPE)] and personal socio-demographic variables in predicting the outcome of psychogeriatric day care. Two groups of elderly patients referred for day care were investigated: 40 new admissions to a psychogeriatric day centre and 63 new admissions to psychogeriatric day hospitals. Discriminant function analysis was employed to compare the classification accuracy obtained from the personal socio-demographic variables and the CAPE psychometric data. The results demonstrated the incremental validity of the CAPE in predicting outcome of day care in both settings and support the routine use of such brief measures as appropriate screening procedures in these settings.

Clinical forensic medicine

This article discusses the merits of participation by medical examiners in the area of clinical forensic medicine. The present connotation that we deal after the fact should be abandoned with enhanced involvement in assisting the living. The paper focuses on a broad range of categories where forensic scientists by virtue of their training and experience could be most helpful in the application of medical knowledge to the solution of questions of law.

Pathogenesis of steatorrhea in primary biliary cirrhosis

To investigate the pathophysiology of steatorrhea in primary biliary cirrhosis, the severity of steatorrhea, small bowel histology and function, cholestasis, exocrine pancreatic secretion and liver histology were studied. Twenty-four primary biliary cirrhotic patients had a quantitative stool fat collection, serum bilirubin and alkaline phosphatase and liver biopsies. From this group, ten had further studies: a small bowel biopsy (n = 7); a D-xylose test (n = 9); measurement of pancreatiobiliary concentrations and outputs after intravenous cholecystokinin (n = 10); essential amino acid perfusion of the duodenum (n = 9), and eating a test meal (n = 7). D-xylose absorption was normal, and only one patient had a minimal small bowel mucosal abnormality. Pancreatic lipase outputs in response to cholecystokinin were low in two primary biliary cirrhotic patients, but were greater than 10% of normal. Postprandial lipase outputs were normal except in one patient who had abnormal duodenal acidification. Mean enzyme outputs in primary biliary cirrhotic patients were normal in response to essential amino acid perfusion; but 6 had low lipase and 5 had low trypsin outputs which were associated with decreased bile acid outputs (p less than 0.03). Severity of steatorrhea was associated with reduced bile acid outputs and concentrations (r = 0.82; p less than 0.0001), degree of cholestasis (serum bilirubin; r = 0.88; p less than 0.001) and advanced histologic stages (p less than 0.005). Severe intraluminal bile acid deficiency combined with a submaximal intraluminal stimulus (essential amino acids) may be associated with decreased exocrine pancreatic secretion in primary biliary cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Histopathological changes in selenium-exposed fish

Redear sunfish (Lepomis microlophus) were collected from Martin Lake in east Texas. For at least 8 months, 1 year earlier, aqueous selenium-laden effluent from man-made sources was released into this 5,000-acre reservoir (unpublished data). Redear sunfish from a reference lake, 8 km upstream, were collected for comparison to Martin Lake fish. The hepatopancreas (i.e., liver and associated, disseminated exocrine pancrease), mesonephros (i.e., kidney), gonads, heart, spleen, stomach, and gill arches were preserved for histopathological examination using optical and/or transmission electron microscopy. Livers from Martin Lake redear sunfish (which had accumulated approximately 20 ppm selenium in the liver) showed central necrosis, reduced quantities of rough endoplasmic reticulum and glycogen particles, and increased numbers of lysosome-like structures. Kidneys showed proliferative glomerulonephritis, and exocrine pancreas showed marked hypertrophy at the optical level. Ultrastructurally, architectural disorganization, reduced rough endoplasmic reticulum, increased cisternal space, and proliferation of smooth endoplasmic reticulum were evident. The stomach, spleen, gill, heart, and gonads showed no abnormalities.

Hepatocyte changes following selenium accumulation in a freshwater teleost

This report provides morphological and analytical data for a group of green sunfish collected from an area relatively free of metals and a second group of the same species collected from a lake into which selenium had been discharged. Neutron activation data of livers (and kidneys) collected from these fish show an average of about 11 ppm selenium (fresh weight) for both organs; other metals were not detected in the liver (or kidneys) of these fish. Ultrastructural examination of livers from fish of this group showed focal necrosis, areas of granular cytoplasm, fatty infiltration, increased numbers of Kupffer cells, and disorganized liver architecture--compared with those of controls. The presence of massive levels of selenium in the liver and concomitant hepatocyte changes suggests a causal relationship between these phenomena.